Missouri Claimed Federal Medicaid Reimbursement for Tens of Millions in Consumer-Directed Personal Care Assistance Services That Did Not Comply With Federal and State Requirements

Why OIG Did This Audit

Consumer-directed personal care assistance (PCA) services assist Medicaid recipients by allowing the consumer (i.e., the recipient) to direct his or her care by hiring, training, supervising, and directing the service worker. In Missouri, the service worker provides assistance with activities of daily living, instrumental activities of daily living, or both, as an alternative to nursing facility placement to persons with a physical disability.

Our objectives were to determine whether Missouri: (1) ensured that consumer-directed PCA services for which it claimed Federal Medicaid reimbursement during fiscal years (FYs) 2018 and 2019 complied with Federal and State requirements, and (2) established and implemented pandemic emergency preparedness standards and protocols within the consumer-directed PCA program.

How OIG Did This Audit

Our audit covered $918 million ($597 million Federal share) in Medicaid payments for consumer-directed PCA services provided and paid for in Missouri during FYs 2018 and 2019.

We reviewed documentation for a stratified random sample of 150 consumer-directed PCA net claim lines of $25 or more (sampled items) to determine whether the services provided were allowable and adequately supported.

What OIG Found

Missouri did not always ensure that the consumer-directed PCA services for which it claimed Federal Medicaid reimbursement during FYs 2018 and 2019 complied with Federal and State requirements. Specifically, 17 of the 150 sampled items were at least partially unallowable because of errors related to: timesheets that could not be provided or that lacked detail; units of service charged that exceeded the number authorized; lack of documentation that attendants were registered, screened, and employable; and recipients with plans of care that were not signed. Based on our sample results, we estimated that Missouri claimed at least $52.5 million ($34.2 million Federal share) for unallowable consumer-directed PCA services during FYs 2018 and 2019. In addition, timesheets for 46 of the 150 sampled items did not identify the specific services that were performed in accordance with the plans of care. We are setting aside, for Centers for Medicare & Medicaid Services (CMS) resolution, an estimated $133.8 million ($87.0 million Federal share) associated with these 46 items.

For our second objective, Missouri did not have established and implemented pandemic emergency preparedness standards and protocols within the consumer-directed PCA program. Most providers for the sampled items did not have any emergency preparedness documentation for a pandemic response.

What OIG Recommends and Missouri Comments

We recommend that Missouri refund the $34.2 million (Federal share) in overpayments to the Federal Government and work with CMS to determine the allowability of the $87.0 million (Federal share) and refund any amount that is determined to be unallowable. We also make procedural recommendations regarding the monitoring of PCA providers and the State's establishment of and adherence to policies and procedures.

Missouri disagreed with most of our findings and recommendations and gave us additional documentation. After reviewing Missouri's comments and the documentation, we revised the number of sampled items in error, from 18 to 17, and revised our statistical estimate and the amount conveyed in our first recommendation. We also removed one procedural recommendation. We maintain that our findings and recommendations, as revised, are valid.